NOCTURNAL SEIZURES COLIN MASSICOTTE RPSGT NOVEMBER 3, 2018 11:30AM-12:15PM
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
NOCTURNAL SEIZURES
COLIN MASSICOTTE RPSGT
NOVEMBER 3, 2018 11:30AM-12:15PM
NOT A LEARNING OBJECTIVE
• To become an EEG expert
– this takes months, years
of practice
Electroencephalography is like a beautiful
park with a sign posted at the entrance:
“For Persons with Total Commitment only”
– Ernst Niedermeyer, MD (1920-2012)
AJET Vol.24, #2, June 1984, p.72
LEARNING OBJECTIVES • Learn basic nomenclature related to seizure activity • Recognize abnormal EEG activity • Be able to respond to patient having a seizure in the sleep lab safely
PRIESTESS OF DELPHI (1891)
John Collier, Art Gallery of South Australia
A Bittersweet Story: The True Nature of the Laurel
of the Oracle of Delphi. Haralampos V. Harissis.
Perspectives in Biology and Medicine, Volume 57,
Number 3, Summer2014, pp. 351-360 (Article).
Published by Johns Hopkins University Press
THE SACRED DISEASE
• Epilepsy known the “sacred disease” in antiquity
• prevailed for many centuries even after Hippocrates expressed his opposition to this widespread belief
in his work On the Sacred Disease (5th C. BCE)
• Aristotle considered sleep “as an epilepsy”
A Bittersweet Story: The True Nature of the Laurel
of the Oracle of Delphi. Haralampos V. Harissis.
Perspectives in Biology and Medicine, Volume 57,
Number 3, Summer2014, pp. 351-360 (Article).
Published by Johns Hopkins University Press
WHAT IS A SEIZURE? WHAT IS EPILEPSY?
• Seizures are changes in awareness or behavior • Epilepsy is the tendency toward recurrent,
brought about by an abnormal discharge of unprovoked seizures
electrical activity in the brain
Kids & Seizures: Know the Hidden Signs. Epilepsy
Foundation fo America. 2008. www.epilepsyfoundation.org
St. Louis, EK. Sleep and Epilepsy: Strange Bedfellows No
More. Minerva Pneumol. 2011 Sep; 50(3): 159–176.
EPILEPSY
• background EEG is usually normal in patients with epilepsy
• abnormal interictal EEG manifestations may include non-epileptiform abnormalities and interictal
epileptiform discharges (IEDs)
• Patients with epilepsy may show generalized or focal slowing of the background, but most useful
diagnostic finding supportive of a diagnosis of epilepsy is the activation of IEDs, which may be either
focal or generalized
• IEDs must be carefully distinguished from benign variants, artifact or normal brain waves to avoid over-
interpretation
Electroencephalography (EEG): An Introductory Text
and Atlas of Normal and Abnormal Findings in Adults,
Children, and Infants [Internet]. Britton JW, Frey LC,
Hopp JLet al., authors; St. Louis EK, Frey LC, editors.
Chicago: American Epilepsy Society; 2016.
EPILEPSY AND SLEEP
• 7.5 to 45 percent of people who have epilepsy have seizures mostly during sleep
• Sleep disorders more prevalent in epileptic population
• Nocturnal seizures usually occur towards the end of the sleep period (5am to 6am)
• Chances of capturing seizure in lab are low, even in patients with known epilepsy
Thomas RH, King WH, Johnston JA, et al Awake
seizures after pure sleep-related epilepsy: a systematic
review and implications for driving law Journal of
Neurology, Neurosurgery & Psychiatry 2010;81:130-
135.
Al-Biltagi MA. Childhood epilepsy and sleepWHY MAY SEIZURES HAPPEN IN SLEEP?
• Epileptic seizures are often strongly influenced by the sleep-wake cycle
• change of state has effect on the brain’s epileptic activity; nocturnal seizures are triggered by changes in
the electrical activity in your brain when moving between the different stages of sleep, and between
sleep and wake
https://www.epilepsy.org.au/about-epilepsy/understanding-
epilepsy/nocturnal-seizures-seizures-during-sleep/NREM
• occurrence of generalized discharges and clinical seizures mainly in NREM sleep, most IEDs in SWS
• can enhance IEDs in both focal and generalized seizures
• seizure activating role of NREM sleep has been attributed to increased neuronal synchronization within
thalamo-cortical projection neurons with robust activation of epileptic ictal and interictal activity
• Most sleep-related seizures start during N2
• few seizures occur during N3 slow wave sleep (SWS)
Al-Biltagi MA. Childhood epilepsy and sleepREM
• REM sleep limits spread of epileptic discharges outside the area that started seizure activity
• Few/no seizures in stage R
Al-Biltagi MA. Childhood epilepsy and sleep
St. Louis EK. Sleep and Epilepsy: Strange Bedfellows No
More. Minerva Pneumol. 2011 Sep; 50(3): 159–176.
St. Louis EK. Sleep and Epilepsy: Strange Bedfellows No
More. Minerva Pneumol. 2011 Sep; 50(3): 159–176.HOW TO RECOGNIZE A SEIZURE
• Short attention blackouts that look like daydreaming, Dazed behavior
• Sudden falls for no reason
• A blank stare, followed by chewing, picking at clothes, mumbling, random
• Lack of response for brief periods movements
• Unusual sleepiness and irritability when wakened from sleep • Sudden fear, anger, or panic for no reason
• Head nodding • Muscle jerks of arms, legs, or body, especially in the early morning
• Rapid blinking • Odd changes in the way things look, sound, smell or feel
• Frequent complaints from the child that things look, sound, taste, smell or feel • Memory gaps
“funny.”
• Dazed behavior
• Clusters of “jackknife” movements by babies who are sitting or laying down
• Being unable to talk or communicate for a short time
• Clusters of grabbing movements with both arms in babies lying on their backs
• Sudden stomach pain followed by confusion and sleepiness
• Repeated movements that look out of place or unnatural
Kids & Seizures: Know the Hidden Signs. Epilepsy
Foundation of America. 2008. www.epilepsyfoundation.orgHOW TO RECOGNIZE SEIZURE ON EEG –
CAN BE CHALLENGING FOR SLEEP TECHS
• number and placement of EEG electrodes
• experience of the sleep tech
• size and location of the ictal generator
• paper speed
Foldvary N, Cosmo Caruso A, Mascha E, Perry M, Klem G,
McCarthy V, Qureshi F, Dinner D. Identifying Montages
that Best Detect Electrographic Seizure Activity During
Polysomnography. SLEEP, Vol. 23, No. 2, 2000HOW TO DESCRIBE WHAT YOU SEE
• Frequency
• Localization
• Amplitude
• Variability
Noachtar S. How to approach EEG and avoid
overreading in epilepsyHOW TO DESCRIBE WHAT YOU SEE
• Frequency
• Localization
• Amplitude
• Variability
Noachtar S. How to approach EEG and avoid
overreading in epilepsyDEFINITIONS
• Interictal epileptiform discharges (IEDs) • Ictal
• EEG isolated spikes, or sharp waves or spike- • EEG contains spikes and sharp waves lasting
wave complexes seconds/minutes
• no behavioural change • usually clinical seizure
American Clinical Neurophysiology Society
Standardized Critical Care EEG Terminology:
2012 versionWHAT IS A SPIKE?
• Epileptogenic waves are made up of spike waves and sharp waves
• spike wave = 20-70 ms while
• sharp waves duration 70-200 ms
• Usually negative (up in PSG)
1s
Epilepsy & Behavior 25(1):137 · July 2012WHAT IS A SPIKE AND WAVE? • 2 different patients with childhood absence epilepsy • (a) A typical spike–wave oscillation (3Hz) • (b) additional spikes may be seen
CLASSIFICATION - INTERNATIONAL LEAGUE AGAINST EPILEPSY
ADVANTAGE OF PSG EEG
• interictal epileptiform discharges (IEDs) most sensitive and specific markers for seizure diagnosis
• routine EEG studies, which typically record for only 20–30 min
• routine EEG chance of recording clinical seizure is rare, IEDs are important
• Longer, ambulatory EEG studies do not provide sufficient information regarding whether a potential
sleep disorder is present due to lack of respiratory and electromyography (EMG) channels
Beyond standard polysomnography: Advantages and
indications for use of extended 10–20 EEG montage
during laboratory sleep study evaluations. Bubrick EJ,
Yazdani S, Pavlov MK. Seizure, Volume 23, Issue 9,
October 2014, Pages 699-702
Chapter 4: EEG Interpretation in Childhood Epilepsies
Charuta N. Joshi, Thoru Yamada in Clinical
Neurophysiology in Pediatrics: A Practical Approach to
Neurodiagnostic Testing and Management by Gloria M.
GallowayADVANTAGE OF PSG EEG
• Seizures can be triggered by OSA which is highly prevalent among adults with epilepsy, with a
prevalence rate around 40%, and is moderate-to-severe in 16%
• OSA fragments sleep and produces a state of chronic sleep deprivation (which increase seizures), one
would expect a benefit from routine screening for OSA in adults with epilepsy
Somboon T, et al. Long-term seizure control in epileptic
patients with obstructive sleep apnea using positive airway
pressure therapy. Presented at: American Epilepsy Society
Annual Meeting; Dec. 1-5; Washington, D.CPractice Parameters for the Indications for Polysomnography and
Related Procedures: “4.4.3.1 Polysomnography, with additional EEG
derivations in an extended bilateral montage, and video recording,
BEST MONTAGE is recommended to assist with the diagnosis of paroxysmal
arousals or other sleep disruptions that are thought to be seizure
related when the initial clinical evaluation and results of a standard
EEG are inconclusive.”
• AASM PSG: Referential montage F4-M1 C4-M1 O2-M1 (backup F3, C3, O1, M2)
• advantages of limited EEG montage include reduced technical time for electrode placement, physician
time for data analysis (and cost of data storage?)
• Difficult to differentiate during PSG between epileptic seizures, non-epileptic behavioral events,
arousals, and artifacts
• many discharges and other EEG abnormalities focal, likely have been missed, misinterpreted, or
required more evaluation if a limited EEG montage was used
Foldvary N, Cosmo Caruso A, Mascha E, Perry M, Klem G,
McCarthy V, Qureshi F, Dinner D. Identifying Montages
that Best Detect Electrographic Seizure Activity During
Polysomnography. SLEEP, Vol. 23, No. 2, 2000.
Beyond standard polysomnography: Advantages and
indications for use of extended 10–20 EEG montage
during laboratory sleep study evaluations. Bubrick EJ,
Yazdani S, Pavlov MK. Seizure. Volume 23, Issue 9,
October 2014, Pages 699-702.WHAT TYPES OF EPILEPSIES FEATURE SLEEP-RELATED
SEIZURES?
• Juvenile Myoclonic Epilepsy (JME)
• Generalized Tonic-Clonic
• Benign Childhood epilepsy with centrotemporal spikes (BECTS) aka Benign Rolandic aka Benign Focal
Epilepsy of Childhood
• Electrical Status Epilepticus of Sleep (ESES or CSWS)
• Lennox-Gastaut Syndrome
• Landau-Kleffner Syndrome (LKS)
• Frontal Onset Seizures (such as Nocturnal Frontal Lobe Epilepsy)
• Nocturnal Temporal Lobe Epilepsy
https://www.epilepsy.org.au/about-
epilepsy/understanding-epilepsy/nocturnal-seizures-
seizures-during-sleep/BENIGN CHILDHOOD EPILEPSY WITH CENTROTEMPORAL SPIKES (BECTS) • Aka Benign Rolandic epilepsy • Focal, idiopathic • Most children will outgrow (starts ~ 3-13 with a peak around 8–9 years and ends around age 14-18) • May feature altered speech, salivation, syncope
BECTS
• Two coexisting types of
benign paroxysm BECTS and
childhood epilepsy with
occipital paroxysm (benign
occipital childhood epilepsy)
in a 10-yo girl with a hx of
generalized tonic-clonic
seizures
• Note the two independent
BECTS at C3/T3 and C4/T4
Yamada T, Meng E. Practical Guide for Clinical
Neurophysiologic Testing: EEG. Philadelphia, PA: Wolters
Kluwer/Lippincott Williams & Wilkins, 2010BECTS
• (A) 12 y.o. girl w. hx of nocturnal generalized tonic-clonic
convulsions with postictal aphasia and right arm weakness
(Todd’s paralysis); EEG shows spikes maximum at C3
• (B) 10-year-old boy w/ hx of nocturnal generalized tonic-clonic
convulsions; EEG shows spikes maximum at T4
Yamada T, Meng E. Practical Guide for Clinical
Neurophysiologic Testing: EEG. Philadelphia, PA: Wolters
Kluwer/Lippincott Williams & Wilkins, 2010GENERALIZED TONIC-CLONIC
Tonic – muscle tone
• Tonic - limbs stiffen, body rigid
• Clonic - after period of stiffening, limbs and face begin to jerk rhythmically
• may have loss of bowel or bladder control
• afterwards: confusion, fatigue, headache
Video: Nguyen Tri Phuong Neurologic DepartmentGENERALIZED TONIC-CLONIC
• Onset of the ictal event in this generalized seizure consists of low-voltage, rhythmic beta-range fast
activity, with progressively increasing amplitude and decreasing frequency
• followed by generalized spike-wave bursts, which become progressively slower in frequency and less
rhythmic toward the end of the seizure
• EEG suppressed during the immediate postictal period and is then followed by the appearance of
postictal delta activity. Clinically, the initial fast activity corresponds with the tonic phase and the
subsequent spike-wave bursts coincide with the clonic phase of the seizure
• During the ictal events, EEG activities are largely obscured by muscle and movement artifacts
Yamada T, Meng E. Practical Guide for Clinical
Neurophysiologic Testing: EEG. Philadelphia, PA: Wolters
Kluwer/Lippincott Williams & Wilkins, 2010GENERALIZED TONIC-CLONIC
• (A) generalized ictal event in a
25-yo man with hx of seizures
since childhood
• Note the sudden flattening of
electroencephalography (EEG)
activity at the onset, followed
by beta activity peeking
through the massive
electromyogram (EMG)
artifact during the tonic phase
of seizure
Yamada T, Meng E. Practical Guide for Clinical
Neurophysiologic Testing: EEG. Philadelphia, PA: Wolters
Kluwer/Lippincott Williams & Wilkins, 2010GENERALIZED TONIC-CLONIC
• (B) Toward the end of the
seizure, ictal discharges
changed to periodic spike-wave
discharges, which were
contaminated by muscle
artifact (clonic phase)
• Afterward, there was postictal
suppression of EEG activity
Yamada T, Meng E. Practical Guide for Clinical
Neurophysiologic Testing: EEG. Philadelphia, PA: Wolters
Kluwer/Lippincott Williams & Wilkins, 2010NOCTURNAL FRONTAL LOBE EPILEPSY • sudden awakening with violent movement, dystonic or tonic posturing, and hyperactive behavior • resembles night terror or RBD • EEG may be normal or may show frontal slowing or spikes • cluster of short fits, rapid start on/off • sudden battering movements during sleep, head jerks to one side, upper limbs rising into brief, frozen state • Behavioral automatisms eg rocking, bicycle pedaling movements and repetitive hand movements
NOCTURNAL FRONTAL
LOBE EPILEPSY
• (A) epileptiform
discharges Wake
• (B) epileptiform
discharges in Sleep
over midline and
frontal region
Successful epilepsy surgery in frontal lobe epilepsy with
startle seizures: a SEEG study. Epileptic Disorders. Volume
17, issue 4, December 2015CASE STUDY 15 YO MALE W GENERALIZED EPILEPSY • Intractable seizures, NDD, autism, nephrocalcinosis • Presented in infancy with West Syndrome • Enalapril, Topamax (topiramate), Zarontin (ethosuximide), Clobazam, vit B6 • Referred for snoring, gasping, pauses in breathing overnight, daytime sleepiness/fatigue, unable to stay awake during the day recently, more frequent naps • initiated on APAP in community
LFF 0.3Hz HFF 35Hz Notch 60Hz Sens 7uV/mm 30s/page 10 mm/s
LFF 0.3Hz HFF 35Hz Notch 60Hz Sens 7uV/mm 30s/page 10 mm/s
LFF 0.3Hz HFF 35Hz Notch 60Hz Sens 7uV/mm 30s/page 10 mm/s
LFF 0.3Hz HFF 35Hz Notch 60Hz Sens 7uV/mm 30s/page 10 mm/s
LFF 0.3Hz HFF 35Hz Notch 60Hz Sens 7uV/mm 30s/page 10 mm/s
LFF 0.3Hz HFF 35Hz Notch 60Hz Sens 7uV/mm 30s/page 10 mm/s
LFF 0.3Hz HFF 35Hz Notch 60Hz Sens 7uV/mm 10s/page 30 mm/s
LFF 0.3Hz HFF 35Hz Notch 60Hz Sens 7uV/mm 30s/page 10 mm/s
LFF 0.3Hz HFF 35Hz Notch 60Hz Sens 7uV/mm
2 min/page
Good ventilation 19/12cmH2O R=12LFF 0.3Hz HFF 35Hz Notch 60Hz Sens 7uV/mm 2 min/page Poor ventilation BiLevel 19/12cmH2O R=12
LFF 0.3Hz HFF 35Hz Notch 60Hz Sens 7uV/mm 30s/page 10 mm/s
LFF 0.3Hz HFF 35Hz Notch 60Hz Sens 7uV/mm 10s/page 30 mm/s
LFF 0.3Hz HFF 35Hz Notch 60Hz Sens 7uV/mm –
10s/page 30 mm/s
Spike-wave complexes 2-4HzLFF 0.3Hz HFF 35Hz Notch 60Hz Sens 7uV/mm
30s/page 10 mm/s
Time: 0526hSo absence in sleep?? Generalized motor seizure with tonic component
BENIGN VARIANTS
• “of uncertain clinical significance”
• E.g. wicket waves, rhythmic mid-temporal theta of drowsiness (RMTD or RTTD), benign small sharp
spikes (BSSS, sometimes denoted BSST for benign small sleep transients), 14 and 6 positive spikes, 6-Hz
“phantom” spike and wave, subclinical rhythmic EEG discharge of adults (SREDA), and the midline theta
rhythm of Ciganek
• Are they reproducible? Play with the software, Filters, Montages, Use the referential montage, Get a
repeat EEG, Get the context
• Many people have IEDs, some will develop epilepsy, some have diagnosed or undiagnosed neurological
conditions but no clinical seizures
Electroencephalography (EEG): An Introductory Text
and Atlas of Normal and Abnormal Findings in Adults,
Children, and Infants. Britton JW, Frey LC, Hopp JLet
al., authors; St. Louis EK, Frey LC, editors.
Chicago: American Epilepsy Society; 2016.HOW DO YOU SCORE IT? • Occasionally whole record will be abnormal EEG, lacking recognizable sleep features
8 y.o. female with Mitochondrial Myopathy, seizure disorder LFF 0.3Hz, HFF 35Hz, notch 60Hz, sens 15uV/mm, 10mm/sec (30s/page)
HOW DO YOU SCORE IT?
• Richard Rosenberg, PhD ‘I wouldn’t even try’
• Use the pediatric scoring set (if available), and
score as NREM vs REM vs W, or even just NREM
vs W
https://www.aastweb.org/blog/author/richard-rosenberg-phdWHAT HAPPENS WHEN A PATIENT HAS A SEIZURE IN THE SLEEP LAB?
HAVE A PLAN (AND KNOW THE PLAN) Before the study: • P&P • Familiarize yourself with the names of anti-epileptic medications • Talk to the patient, ask about seizures - when diagnosed? controlled? when was last seizure? how does it manifest?
KNOW THE COMMON TRIGGERS
• Sleep deprivation
• Alcohol intake
• Stress
• OSA
• photosensitive patients, seizures can be precipitated by television
https://www.epilepsy.com/learn/professionals/refractor
y-seizures/actions-take/identify-and-reduce-triggers
Elger CE, Schmidt D. Modern management of epilepsy.
Epilepsy Behav 2008;12:501-39.EPILEPSY ACTION PLAN - IS IT AN EMERGENCY?
A seizure is generally considered an emergency when:
• Convulsive (tonic-clonic) seizure lasts longer than 5 minutes
• Or repeated seizures without regaining consciousness
• = Status Epilepticus
• types of status epilepticus: convulsive and non-convulsive
• Convulsive status epilepticus requires emergency treatment
by trained medical personnel in a hospital setting as it may be
life-threatening
https://www.epilepsy.com/sites/core/files/atoms/file
s/seizure-action-plan-pdf_0.pdfEPILEPSY ACTION PLAN
• Communication - other techs
• Be reassuring, comforting and stay calm
• Track and record time, and note as much detail as possible (time, description of movements)
• Basic 1st aid:
• Environment - recovery position, remove objects, protect head (pillows, rolled up sheets)
• Do not restrain
• Do not put anything in mouth
• Keep airway open and watch breathing
• Stay with them until fully conscious
• Call your MD
https://www.epilepsy.com/sites/core/files/atoms/file
s/seizure-action-plan-pdf_0.pdfDIFFERENTIAL DIAGNOSIS
• 3 m.o. infant, in PICU, grandma reports frequent
seizures
“His eyes go all ‘funny’. I’ve had 3 children
• Upon pre-study interview, reported to sleep
and many grandchildren and none of
tech unusual eye movements when asleep
them ever did this”
• EEG showed normal sleep stages, no apparent
spikes/spike waves, no clinical seizures
• LAMF, low chin EMG, and eye movements “Oh look, there he goes, he’s doing it!”QUESTIONS?
colin.massicotte@sickkids.caYou can also read
